Mark K Lecture 6: Drug Toxicities (Lithium, Lanoxin, Dilantin, Bilirubin, Aminophylline, Kernicterus, Dumping/ HH Electrolytes, K+, Ca, Mg, and Na+

Lithium

Anti-mania Drug

Used for mania in bipolar depression

Therapeutic level: 0.6- to 1.2

Toxic Level: > 2.0

Lanoxin or Digoxin

Used to treat A-Fib and CHF

Therapeutic level: 1 to 2

Toxic level: >2

Aminophylline

Muscle Spasm relaxer for the airway

Compound of the bronchodilator theophylline, but this med IS NOT a bronchodilator

Therapeutic level: 10-20

Toxic level: >20

Non-therapeutic level: <10 if it is not therapeutic, increase dose of medication, and assess for complicnace

Dilantin (phenytoin)

Seizure medication

Therapeutic level: 10-20

Toxic level: >20

Bilirubin

Breakdown product of RBCs

Normal level in adult: 0.2 to 1.2

Always tested in the Newborns on the NCLEX

In Newborns bilirubin is much higher than in adults (they are breaking down mom's RBCs)

Elevated level: 10-20 toxicity

Toxicity:>20

We hospitalize newborns when their bilirubin is about 14-15

Patterns for Drug Tox

1s and 10s

2s: Low, Lithium and Lanoxin

20s: High, Aminophyline, Dilantin, and Bilirubin

Kernicterus means

excess bilirubin in the BRAIN

occurs when level in the blood gets >20

may cause aseptic meningitis or encephalopathy

Jaundice means

bilirubin in the skin

Opisthotonos is the

position the newborn assumes due to irritation of the meninges from kernicterus

hyperextended posture

medical emergency

In what position do you place a child in opisthotonos posture?

on their side

What is the difference btw Pathological and Physiological Jaundice?

Patho: newborn is born yellow

Physio: newborn turns yellow 2-3 days postpartum

Hiatal Hernia

The regurgitation of acid into esophagus, because upper stomach herniates upward through the diaphragm

gastric contents move in the WRONG direction at the RIGHT rate

S&Sx: upper GI signs when you lie down after eating (similar to GERD)

Treatment:

elevate HOB

Increase the amount of fluids with meals

increase the amount of carb content

LOW protein

These cause the stomach to empty quickly so it is content and does not back up

High-atal Hernia EVERYTHING HIGH

Dumping Syndrome

Gastric contents empty too rapidly into the duodenum

RIGHT direction but WRONG rate

S/Sx: like they are drunk: staggering gate, impaired judgment, labile, all blood goes to the gut, also can get shock, cold/clammy, tachycardia, n/v, diarrhea, cramping, guarding, borborygmi, bloating, distention

So dumping syndrome= acute ABD, drunk, shock

Treatment:

Lower HOB during meals and turn patient on the side

Lower the amount of fluids 1-2hrs before or after meals

Lower carb content, HIGH protein

if you want the stomach to go slow go low (except for protein)

What should you memorize about K+?

Kalemias do the same as the prefix hypo-, hyper-) except for HR and urine which go opposite

Hyper;

Brain: seizures, agitation, irritability

Heart: tented T waves, ST elevation, tachypnea

GI: diarrhea, borborygmi

Muscle: spasticity, increased tone, hyperreflexia

Heart Rate goes DOWN

Urine Output does DOWN

Hypo:

Lethargy, bradypnea, paralytic illeus, constipation muscle flaccidity, hyporeflexia

Tachycardia

Polyuria

What should you memorize about Ca?

Calcemias do the opposite as the prefix

Hypo- symptoms go HIGH, agitation, irritability, hyperreflexes, spasms, seizure, Chvosteck sign positive (cheek), Trousseau (hand flex with BP cuff)

Hyper- symptoms go LOW, bradycardia, bradypnea, flaccid, , lethargy, constipation

What should you memorize about Mg?

Magnesemias do the opposite as the prefix

What should you memorize about Na+?

HypOnatremia= volume Overload; crackles, distended neck veins, crackles, distended neck veins-> fluid restriction, lassie

HypErhatremia=dEhydration; hot, flushed, dry skin, thready pulse, rapid HR-> GIVE FLUIDS

It is possible that the s/sx are from several electrolyte imbalances, so what do you do then?

choose Ca+ if nerve or skeletal muscle involved

choose K+ for any other symptom and generally anything effecting blood pressure

In addition to high K+ what other electrolyte abnormalities can be seen in DKA?

Hypernatremia= Dehydration

DKA should make you think of Dehydration, which is also associated with hypErnatremia

How to spot early signs of any electrolyte disturbance?

the earliest sign of any electrolyte disturbance

numbness and tingling= parathesia

circumoral paresthesia= numbness and tingling around the lips

universal sign of all electrolyte imbalances is muscle weakness=paresis

Treatment need to know (only test K+)

NEVER PUSH IV K+

Potassium <40 mEq/L of IV fluid, if > 40 clarify dosage

How do you LOWER K+?

High K+ stops the heart= most problematic

the fastest way to lower K+ is to give D5W and regular insulin

this is a TEMPORARY solution but a fast one

Kayexalate is a long-term solution

through enema or ingestion, kayexalate exchanges K+for Na+

K Exits Late (works is a few hours)

YOU CAN GIVE ALL 3